The NHS – kill or cure? STP knowns and unknowns

Sustainability & Transformation Plans (STPs) being prepared across the country on the orders of NHS chief Simon Stevens. There is a plausible view that they present the greatest threat to the NHS since the 1948 settlement. Although there is much that we don’t know, veils are removed almost every day.

This is a brief account of what we have so far gleaned. We don’t think we should delay further sharing it with our readers. What follows is based on a note we sent to Brent’s Chief Executive, Carolyn Downs, for a meeting she kindly offered us on 1st June about the process for preparing these plans. She is the local government lead for the 8 NW London boroughs.

Overall the national STP process as well as its local iteration appears to be radical and internally self-contradictory, but moving forward in semi-secrecy at an unacceptable speed. If it was clear that clinicians and other professionals who deliver care, as well as the wider public, were going to have a proper input before STPs were finalised and implemented we would be content to wait for our turn. However this does not seem to be the case.

By virtue of the NHSE National Planning Guidance for 2016/2017 NHS CCGs and Trusts are required to produce and submit STPs in outline (checkpoint) form by mid-April and in full by the end of June, with implementation beginning in October. Local authorities, though not subject to NHSE jurisdiction, are to be engaged in the process of production. Clinicians and patients are to be involved, presumably after the full STP has been submitted. STPs cover newly-created areas called “footprints”. In the case of our area the footprint consists of the 8 boroughs already grouped together for the purpose of ‘Shaping a Healthier Future’, ‘Whole Systems Integrated Care’ and ‘Transforming Primary Care’.

The main purposes of STPs are

  • to speed up implementation of the changes in ways of working between hospitals, GPs and community services outlined in The Five Year Forward View and;
  • to eliminate financial deficits, i.e. spending above budgets, in short order.

The Guidance makes no reference to current NHS shortcomings, pressures, staff shortages or population growth but strongly asserts that in the short term better services can be delivered with fewer resources. It has a list of questions to be answered which seem likely to provoke cynicism among front line staff.

The NHSE publication: General Practice: the Five Year Forward View issued on 21 April 2016 with Introduction by Simon Stevens describes a major transformation of NHS GP practices that Sarah McDonnell for Brent CCG recently described at the Brent Health and Wellbeing Board as a ‘cottage industry’, and Dr Sarah Basham characterised as ‘getting more corporate’. This is set out in Chapter 5 at page 49.

The vehicle proposed for this transformation is the new ‘Multispeciality Community Provider‘(MCP) contract:

“Today the range of services funded within general practice owes much to history rather than optimal working arrangements for GPs or patients. The MCP model is about creating a new clinical model and a new business model for the integrated provision of primary and community services, based on the GP registered list, but fully integrating a wider range of services and including relevant specialists wherever that is the best thing to do, irrespective of current institutional arrangements. At the heart of the MCP model the provider ultimately holds a single whole population budget for the full breadth of services it provides, including primary medical and community services.”

So-called Accountable Care Partnerships, including GP federations with patient lists averaging 170,000, would be formed to provide these services in place of the old model of care with the individual GP practice at the centre, going back to the 1948 origins of the NHS. These would still need to address the long-standing problem as to who pays when long-term residential care is needed for individuals who should not be in hospital but cannot care for themselves at home. The current shortfall in social care funding, even when supplemented by the Better Care Fund, only exacerbates this dilemma. These deep issues are not going to be solved by a series of hastily written and implemented STPs.

Moreover this is the point at which the STP process becomes self-contradictory. The major change in primary care, the “new model of care”, has not begun to be sold to GPs and the public, far less designed and accepted. It will need time and a good deal of money to be tested and to demonstrate its advantages. This is completely inconsistent with a requirement to eliminate NHS deficits in a couple of years or even less.

The trend in NHS Trust deficits is moving sharply downwards from a surplus 4 years ago to £800m in 2015 and £2.45bn this year (though experts say the true figure is closer to £3bn). Rising demand, higher costs of agency staff because permanent staff are not available and over-use of management consultants are factors. There is no evidence that this trend can be significantly reversed over the five-year planning period without reductions in the care delivered. Most key care outcome indicators are already on a downward trend.

Some questions and issues

  1. Is not a candid analysis of the current situation and immediate prospects the essential basis for realistic STP planning?
  2. Can such planning be done without full involvement of medical and social care professionals?
  3. Does not the recent dispute with junior hospital doctors just highlight the deterioration in relations between core staff and political leadership, whereas trust between these two elements in the system is essential for successful reform?
  4. Why has the national political leadership made no effort to justify to Parliament and the public the major changes in GP/patient relationship envisaged by the Five Year Forward View proposals for transforming primary care?
  5. Is not the structure of the footprints (and regional leaders above the footprints) where official representatives are meant to have delegated powers to commit their organisations an attempt to sidestep the legislation of the Health and Social Care Act 2012 with its devolved and GP-led commissioning by a centralised top-down planning system without any recourse to fresh legislation?
  6. How can the secretive and rushed process for STPs ordained by Simon Stevens end up securing any measure of public consent? When is serious public and clinical engagement going to begin?
  7. Is it not the case that projects to group GPs into federations working with other providers to deliver packages of care in the community or “out of hospital” will not deliver savings in the short term – even if GPs manage to understand and approve of them – with the consequence that closing acute hospital beds and A&E departments (in NW London 500 beds and two more A&E’s) becomes once again the preferred method of acceding to HM Treasury demands?
  8. Bearing in mind that outline STPs already submitted are not in the public domain and that local authorities are party to them, have elected Brent councillors seen and approved them or authorised officials to proceed without reference to them? Will the final STP submissions be considered in public before submission at the end of June?
  9. Should we not recognise that the health and social care workforce is going flat out and that there are no more large “efficiency savings” to extract under the present financial settlement? Is not the underlying question here how much the UK taxpayer wishes to spend on health and social care as a proportion of GDP if the NHS ‘free at the point of delivery model” is to be preserved? Or is the intention of this Government initiative to facilitate an extension of commercial provision of NHS medical and local authority social care?

Robin Sharp and Peter Latham

Brent Patient Voice

31st May 2016

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